HIV as a Risk Factor for TB Henry Pacheco, MD November 13, 2008

Transcription

1 Tuberculosis Updates for Clinicians San Antonio, Texas November 13, 2008 HIV as a Risk Factor for TB Henry Pacheco, MD November 13, 2008 HIV as a Risk Factor for TB Tuberculosis Update for the Clinician San Antonio, Texas Nov 13, 2008 Henry Pacheco, M.D. Texas/Oklahoma AIDS Education & Training Center 1

2 Objectives: Describe the risk of TB disease in HIV+ patients. Prevalence of TB in HIV+ patients Importance of knowing HIV status if infected with TB Discuss the importance of screening HIV+ patients for tuberculosis. Risk of progression to TB disease in HIV+ patient Managing HIV in a TB patient - Managing TB in a HIV+ patient HIV & TB TB is the most common opportunistic infection among people living with HIV (PLWH) TB is associated with substantial morbidity and mortality among PLWH Treating HIV & TB at the same time is complex requiring multidrug therapy. ARV therapy can be life-saving for those with TB and advanced HIV disease. Source CDC/ DTEB 2

3 HIV and TB Patients Knowing the HIV status of TB patients is essential to optimal patient management Patients with both TB & HIV infection are 5 times more likely to die during TB treatment than patients not HIV infected. HIV infection is the greatest known risk factor for progression from latent TB to active TB disease. After TB exposure/infection PLWH who are not treated progress to TB disease over 5 years at a rate 10X greater than those HIV negative MMWR October 26, 2007 / 56(42); Natural Course of HIV Infection and Opportunistic Diseases (Source WHO) CD4+ cell Count TB CD4+ T cells TB HZV OHL Viral Load TB PP E OC PCP TB CM CMV, MAC Months Years 3

4 Prevalence Estimated TB incidence rate, 2006 Estimated new TB cases (all forms) per population No estimate or more The boundaries and names shown and the des ignat ions used on th i s map do not imply the express ion of any opinion whatsoever on the part of the World Health Organizat i on concerning the legal status of any country, territory, c i ty or area or of its authorit ies, or concerning the del im itat i on of i ts front i ers or boundaries. Dotted l ines on maps represent approx imate border l ines for which there may not yet be ful l agreement. WHO A ll rights reserved 4

5 Reported TB Cases* United States, No. of Cases 28,000 26,000 24,000 22,000 20,000 18,000 16,000 14,000 12,000 10, Year *Updated as of April 23, TB Morbidity United States, Year No. Rate* , , , , , , *Cases per 100,000, updated as of April 23,

6 TB Case Rates,* United States, 2007 D.C. *Cases per 100,000. < 3.5 (year 2000 target) > 4.4 (national average) Reported TB Cases by Origin and Race/Ethnicity,* United States, 2007 U.S.-born American Indian or Alaska Native (3%) Asian (2%) Foreign-born** White (5%) White (33%) Hispanic or Latino (38%) Asian (43%) Native Hawaiian/Other Pacific Islander (<1%) Hispanic or Latino (17%) Black or African American (45%) Black or African American (13%) *All races are non-hispanic. Persons reporting two or more races accounted for less than 1% of all cases. **American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander accounted for less than 1% of foreign-born cases and are not shown. 6

7 Number of TB Cases in U.S.-born vs. Foreign-born Persons United States, * No. of Cases U.S. -born Foreign-born *Updated as of April 23, TB & HIV Prevalence in the US 2005 ~ 1 million people are living with HIV ~ 9 14 million are infected with TB, and If not treated, active TB will develop in 5% to10%. ~ 9% of all TB cases, and nearly 16% of TB cases among those aged occurred in PLWH Those dually infected, are at very high risk for active and contagious TB disease 63% of those TB patients reported to be infected with HIV, were non-hispanic blacks Source CDC

8 HIV Status of TB Patients in US Reporting of HIV status of TB patients increased from 35% in 1993 to 68% in 2003 In 2005, 69% of 11,193 TB patients in the US had known HIV status and for 31% of TB patients it was unknown 9% -13% of TB patients were HIV positive in 2005 Increased routine and rapid HIV testing may increase acceptability of testing, allowing healthcare providers to know the HIV status of a greater percentage of TB patients and enable them to provide optimal care MMWR October 26, 2007 / 56(42); TB Patients at Greater Risk for HIV Infection Injection-drug users (IDUs) and other-drug users (NIDUs) Homeless persons The poor Correctional facility inmates Alcohol abusers Higher prevalence in the foreign-born Among the U.S. born - LTBI was associated with African-Americans and Mexican-Americans 8

9 Here in Texas 9

10 Texas Counties With Higher Than Average Incidence of TB Highest Risk (2X TX Av.) Cameron Frio Irion Kinney La Salle Maverick Reeves Sterling Val Verde Ward Webb Zapata Higher Risk (1.5-2 x TX Av.) Culberson Dallam Dallas Harris Hidalgo Jeff Davis Palo Pinto Parmer Presidio Starr TDCJ 10

11 HIV in Texas ,571 people living with HIV/AIDS Net Increase ~ 4,000 case/year (5000 new cases, 1000 deaths) PLWH/A increased by 33% in past 5 yrs. 1 in 3 Texans with HIV are diagnosed with AIDS within 1 year of their first HIV + test 1/2 of all PLWHA live in Dallas & Houston African Americans account for 38.2%, compared to 37% Anglo and 23% Hispanic Source: TX DSHS The Need to Seek and Treat 11

12 Multidrug Resistant Tuberculosis & HIV 26 FEBRUARY 2008 WASHINGTON DC /GENEVA - Multidrug-resistant tuberculosis (MDR-TB) has been recorded at the highest rates ever, according to a new report published today. The report presents findings from the largest survey to date on the scale of drug resistance in tuberculosis. The report, "Anti-tuberculosis drug resistance in the world", is based on data collected between 2002 and 2006 on TB patients in 81 countries. It found that extensively drug-resistant tuberculosis (XDR-TB), a virtually untreatable form of TB, has been recorded in 45 countries. The report also found a link between HIV infection and MDR- TB. Surveys in Latvia and Ukraine found nearly twice the level of MDR-TB among TB patients living with HIV compared with patients without HIV. Source : W.H.O. 12

13 In 2006, CDC calls for Routine HIV Screening of all TB patients After notification that testing will be performed (opt-out screening) Enabling optimal patient management Knowing the HIV status of TB patients helps public health agencies to identify HIV-infected contacts of TB patients Highly active antiretroviral therapy (HAART) can reduce the progression to TB disease, TB relapse and death CDC Recommendations for HIV Screening in TB Clinics Updated: April 2008 CDC recommends HIV screening for all TB patients after the patient is notified that testing will be performed, unless the patient declines (i.e., opt-out screening) Routine HIV testing is also recommended for persons suspected of having TB disease and contact with TB patients Persons at high risk for HIV infection should be screened for HIV at least annually Prevention counseling and separate written consent for HIV testing should no longer be required 13

14 2006 CDC Issues Revised Recommendations for HIV Screening Why the rush?!? 14

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17 Changes in CDC Recommendations Using opt-out HIV screening Annually screening persons at high risk for HIV Eliminating the need for separate written consent for HIV testing Eliminating the need for prevention counseling as part of routine HIV screening. 17

18 TEXAS % of Persons with HIV and AIDS Diagnoses within 1 Month and 1 Year Total w/i 1 month w/i 1 year Male w/i 1 month w/i 1 year Female w/i 1 month w/i 1 year White w/i 1 month w/i 1 year Black w/i 1 month w/i 1 year Hispanic w/i 1 month w/i 1 year

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21 TX/OK AETC Trainings Didactic/lecture presentations Interactive and skills-building, active trainee participation Clinical preceptorships, hands-on learning, active involvement with patients Clinical consultation, Patient-specific Technical assistance, capacity building and referral, organization or program structure TB & HIV Web Resources 21

22 TB and HIV Co-infection CDC Educational Brochure Dual Infection: HIV and TB Susceptibility Presentation HIV TB Disease progression Mortality 22

23 The Bottom Line! There is overlapping Epidemiology of HIV and TB infection in many cases Screening for TB should be part of the initial assessment of HIV-infected patients and repeated annually in high-risk individuals if the test result is negative. It is recommended that all patients with tuberculosis have testing for HIV infection, at least by the time treatment is initiated, if not earlier. Thank You! For more information about the TX/OK AETC Please contact: Henry Pacheco, MD (214)

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